Descriptive Analysis of Patient Misidentification From Incident Report System Data in a Large Academic Hospital Federation.

INTRODUCTION

Patient misidentification continues to be an issue in everyday clinical practice and may be particularly harmful. Incident reporting systems (IRS) are thought to be cornerstones to enhance patient safety by promoting learning from failures and finding common root causes that can be corrected. The aim of this study was to describe common patient misidentification incidents and contributory factors related to perioperative care.

DESIGN AND SETTINGS

We retrospectively analyzed IRS data reported by healthcare workers from a large academic hospital federation from 2011 to 2014. All patient misidentification incidents that occurred during perioperative care were reviewed and classified using the international classification for patient safety taxonomy. Incident type, contributory factor, error type, and consequences for the patient and for the organization were extracted for each incident report.

RESULTS

Among the 293 reported incidents, the most frequent errors were missing wristbands (34%), wrong charts or notes in files (20%), administrative issues (19%), and wrong labeling (14%). The main contributory factors included the absence of patient identity control (30%), patient transfer (30%), and emergency context (8%). Data on patient and institutional consequences were scarce. Events of missing and wrong identities on wristbands were rarely detected when patients were transferred from the admission ward to the operating room or the radiology department.

CONCLUSION

These results illustrate that misidentification errors are still common in France. This work contributes to enhancing interest in IRS data analysis to define or refine patient safety improvement strategies related to misidentification errors in healthcare institutions.